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Congenital dislocation of the patella — the genetics and conservative management
The Knee 6 Ž1999. 225]226
Letter to the editor
Congenital dislocation of the patella } the genetics and conservative management Accepted 28 June 1999
Dear Sir We read with interest the article by Robinson et al. entitled ‘Congenital dislocation of the patella } the genetics and conservative management’ w1x. It is obviously important to determine the natural history of any condition that we manage and this has been well addressed in their case report of this rare condition. They conclude, patients’ can function fairly well with untreated congenital permanent dislocation of the patella, although with some weakness of extensor function. Early reports of surgical realignment of the patella, met with variable success w2]4x. However, there is a technique described in the paediatric orthopaedic literature which gives goodrsatisfactory results in the surgical treatment of this condition with restoration of active knee extension. This technique was described by Langenskiold and Ritsila w5x and utilises medial transfer of the patella tendon through a staggered tunnel in the synovial membrane and fibrous capsule of the knee joint. They used it on 18 knees in 12 children with a mean follow-up of over 13 years with active restoration of knee extension reported in all cases. We have used this particular technique on one occasion in a child with congenital dislocation of the patella bilaterally, who was severely mentally handicapped, generally lax and could walk only a few steps in a walking frame. He presented initially aged 8 years with bilateral dislocated patellae and valgus knees that was worse on the right. The left side was reducible in extension, but the right was irreducible. He underwent bilateral proximal and distal realignment procedures. The left side reduced fully, but the right side was still subluxing at surgery with a very
hypoplastic trochlea grove. He was in plaster for 6 weeks post-operatively. However, the right went on to re-dislocate and he developed a 308-fixed flexion and a 208-fixed valgus deformity of his right knee. At the age of 11 years, he underwent a right Langenskiold procedure w5x followed by plaster immobilisation for 6 weeks. At the most recent follow-up, approximately 1 year post-op, the valgus deformity remained fully corrected, he had a residual 108-fixed flexion deformity and his patella appeared to be tracking normally. He had no pain in that knee and had good active straight leg raise. He was able to stand in a standing frame with a much-improved posture. Therefore, although we agree that conservative treatment of this condition does have a place, attempted surgical reduction and stabilisation of the patella has much to offer, even in the older child. Formalised outcome studies of differing treatment methods are probably not possible in this rare condition. Therefore the surgeon must manage each case based on individual needs using treatments which will achieve the defined goals. We feel that the technique described by Langenskiold and Ritsila w5x, is a good surgical method of treating this condition which all surgeons dealing with these patients, should be aware of.
0968-0160r99r$ - see front matter Q 1999 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 9 9 . 0 0 0 2 3 - X
S. Jari R.W. Paton Department of Orthopaedic Surgery Blackburn Royal Infirmary Bolton Road Blackburn BB2 3LR UK
226
S. Jari r The Knee 6 (1999) 225]226
References w1x Robinson AHN, Aladin A, Green AJ, Dandy DJ. Congenital dislocation of the patella } the genetics and conservative management. Knee 1998;5:235]237. w2x Conn HR. A new method of operative reduction for congenital luxation of the patella. J Bone Jt Surg 1924;7:370]381.
w3x Stanisavljevic S, Zemenick G, Miller D. Congenital, irreducible, permanent lateral dislocation of the patella. Clin Orthop 1975;116:190]199. w4x Jones RDS, Fisher RL, Curtis BH. Congenital dislocation of the patella. Clin Orthop 1975;119:177]183. w5x Langenskiold A, Ritsila V. Congenital dislocation of the patella and its operative treatment. J Pediatr Orthop 1992;12:315]323.
Letter to the editor
Congenital dislocation of the patella } the genetics and conservative management Accepted 28 June 1999
Dear Sir We read with interest the article by Robinson et al. entitled ‘Congenital dislocation of the patella } the genetics and conservative management’ w1x. It is obviously important to determine the natural history of any condition that we manage and this has been well addressed in their case report of this rare condition. They conclude, patients’ can function fairly well with untreated congenital permanent dislocation of the patella, although with some weakness of extensor function. Early reports of surgical realignment of the patella, met with variable success w2]4x. However, there is a technique described in the paediatric orthopaedic literature which gives goodrsatisfactory results in the surgical treatment of this condition with restoration of active knee extension. This technique was described by Langenskiold and Ritsila w5x and utilises medial transfer of the patella tendon through a staggered tunnel in the synovial membrane and fibrous capsule of the knee joint. They used it on 18 knees in 12 children with a mean follow-up of over 13 years with active restoration of knee extension reported in all cases. We have used this particular technique on one occasion in a child with congenital dislocation of the patella bilaterally, who was severely mentally handicapped, generally lax and could walk only a few steps in a walking frame. He presented initially aged 8 years with bilateral dislocated patellae and valgus knees that was worse on the right. The left side was reducible in extension, but the right was irreducible. He underwent bilateral proximal and distal realignment procedures. The left side reduced fully, but the right side was still subluxing at surgery with a very
hypoplastic trochlea grove. He was in plaster for 6 weeks post-operatively. However, the right went on to re-dislocate and he developed a 308-fixed flexion and a 208-fixed valgus deformity of his right knee. At the age of 11 years, he underwent a right Langenskiold procedure w5x followed by plaster immobilisation for 6 weeks. At the most recent follow-up, approximately 1 year post-op, the valgus deformity remained fully corrected, he had a residual 108-fixed flexion deformity and his patella appeared to be tracking normally. He had no pain in that knee and had good active straight leg raise. He was able to stand in a standing frame with a much-improved posture. Therefore, although we agree that conservative treatment of this condition does have a place, attempted surgical reduction and stabilisation of the patella has much to offer, even in the older child. Formalised outcome studies of differing treatment methods are probably not possible in this rare condition. Therefore the surgeon must manage each case based on individual needs using treatments which will achieve the defined goals. We feel that the technique described by Langenskiold and Ritsila w5x, is a good surgical method of treating this condition which all surgeons dealing with these patients, should be aware of.
0968-0160r99r$ - see front matter Q 1999 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 9 9 . 0 0 0 2 3 - X
S. Jari R.W. Paton Department of Orthopaedic Surgery Blackburn Royal Infirmary Bolton Road Blackburn BB2 3LR UK
226
S. Jari r The Knee 6 (1999) 225]226
References w1x Robinson AHN, Aladin A, Green AJ, Dandy DJ. Congenital dislocation of the patella } the genetics and conservative management. Knee 1998;5:235]237. w2x Conn HR. A new method of operative reduction for congenital luxation of the patella. J Bone Jt Surg 1924;7:370]381.
w3x Stanisavljevic S, Zemenick G, Miller D. Congenital, irreducible, permanent lateral dislocation of the patella. Clin Orthop 1975;116:190]199. w4x Jones RDS, Fisher RL, Curtis BH. Congenital dislocation of the patella. Clin Orthop 1975;119:177]183. w5x Langenskiold A, Ritsila V. Congenital dislocation of the patella and its operative treatment. J Pediatr Orthop 1992;12:315]323.